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 Table of Contents     
UNUSUAL CASE
Year : 2017  |  Volume : 13  |  Issue : 2  |  Page : 143-145
 

Portomesenteric venous thrombosis: A rare but probably under-reported complication of laparoscopic surgery: A case series


1 Department of Upper Gastrointestinal Surgery, Lancashire Teaching Hospitals NHS Trust, Preston, UK
2 Department of Radiology, Lancashire Teaching Hospitals NHS Trust, Preston, UK
3 Department of Colorectal Surgery, Lancashire Teaching Hospitals NHS Trust, Preston, UK

Date of Submission20-Jun-2016
Date of Acceptance15-Aug-2016
Date of Web Publication9-Mar-2017

Correspondence Address:
Ravindra S Date
The University of Manchester, Manchester Academic Health Science Centre, Lancashire Teaching Hospital NHS Foundation Trust, Chorley PR7 1PP
UK
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-9941.195582

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 ¤ Abstract 

Portomesenteric venous thrombosis (PMVT) is a rare but well-reported complication following laparoscopic surgery. We present three cases of PMVT following laparoscopic surgery. Our first case is a 71-year-old morbidly obese woman admitted for elective laparoscopic giant hiatus hernia (LGHH) repair. Post-operatively, she developed multi-organ dysfunction and computed tomography scan revealed portal venous gas and extensive small bowel infarct. The second patient is a 51-year-old man with known previous deep venous thrombosis who also had elective LGHH repair. He presented 8 weeks post-operatively with severe abdominal pain and required major bowel resection. Our third case is an 86-year-old woman who developed worsening abdominal tenderness 3 days after laparoscopic right hemicolectomy for adenocarcinoma and was diagnosed with an incidental finding of thrombus in the portal vein. She did not require further surgical intervention. The current guidelines for thromboprophylaxis follow-up in this patient group may not be adequate for the patients at risk. Hence, we propose prolonged period of thromboprophylaxis in the patients undergoing major laparoscopic surgery.


Keywords: Complication, laparoscopic surgery, portomesenteric venous thrombosis


How to cite this article:
Goh YM, Tokala A, Hany T, Pursnani KG, Date RS. Portomesenteric venous thrombosis: A rare but probably under-reported complication of laparoscopic surgery: A case series. J Min Access Surg 2017;13:143-5

How to cite this URL:
Goh YM, Tokala A, Hany T, Pursnani KG, Date RS. Portomesenteric venous thrombosis: A rare but probably under-reported complication of laparoscopic surgery: A case series. J Min Access Surg [serial online] 2017 [cited 2017 Oct 21];13:143-5. Available from: http://www.journalofmas.com/text.asp?2017/13/2/143/195582



 ¤ Introduction Top


Portomesenteric venous thrombosis (PMVT) is a rare but well-documented complication following laparoscopic surgery. PMVT, generally, presents 2 weeks post-operatively.[1] The presentation of PMVT is non-specific, and as a result, the diagnosis is often delayed or incidental.


 ¤ Case Reports Top


Case 1

A 71-year-old woman was admitted for elective laparoscopic giant hiatus hernia (LGHH) repair. She was morbidly obese with asymptomatic varicose veins. Intra-operatively, she had large hiatus hernia with two-third of the stomach in the mediastinum. Her surgery was difficult and operating time was approximately 3½ h. Intra-abdominal pressure was maintained at 12 mmHg throughout the surgery. Intermittent pneumatic compression was commenced intra-operatively. In the post-operative period, she was admitted to high dependency unit and thromboprophylaxis was commenced. She had a stormy post-operative course and developed acute kidney injury, sepsis and severe lactic acidosis requiring haemodialysis and supportive therapy. Computed tomography (CT) of the abdomen and pelvis revealed an extensive small bowel infarct involving the greater curvature of the stomach wall and portal venous gas within the left lobe of the liver [Figure 1]. She developed multi-organ dysfunction and the decision was made for supportive care and palliation. This patient died a week after surgery.
Figure 1: Extensive small bowel infarct involving the greater curvature of the stomach and portal venous gas

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Case 2

A 51-year-old man was referred to this tertiary centre with severe reflux, intolerance to solids, vomiting and weight loss. He was on long-term warfarin for a deep vein thrombosis. pH manometry showed a DeMeester score of 18.4%. He underwent LGHH, Nissen fundoplication, gastropexy and on table gastroscopy. Pneumoperitoneum, intra-operatively, was maintained at 15 mmHg. Post-operatively, the patient was continued on therapeutic enoxaparin (1.5 mg/kg) and intermittent pneumatic compression overnight. He made an uneventful recovery and was discharged 3 days post-operatively with a plan to continue on therapeutic doses of enoxaparin until his international normalised ratio had returned to target range.

Eight weeks post-operatively, he presented as an emergency to his local hospital with peritonitis. Intra-operative findings at emergency subtotal colectomy and formation of ileostomy showed faecal peritonitis secondary to perforated gangrenous bowel. The patient was managed in the Intensive Care Unit post-operatively. He is awaiting reversal of his stoma.

Case 3

An 86-year-old woman with significant comorbidities underwent uneventful laparoscopic right hemicolectomy for Duke's B adenocarcinoma. She was commenced on thromboprophylaxis post-operatively. On post-operative day 3, she was pyrexia and complained of worsening abdominal tenderness. A CT of the chest, abdomen and pelvis performed revealed a thrombus in the portal vein [Figure 2]. She was commenced on treatment doses of enoxaparin (1.5 mg/kg) for a total of 3 months. She did not require any further surgical intervention. Follow-up at 6 weeks was unremarkable.
Figure 2: Thrombus in the portal vein

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 ¤ Discussion Top


In this case series of three patients, we report mortality of one patient as a result of PMVT causing bowel infarction and morbidity in another, who required major bowel resection.

The aetiology of venous thrombosis is often multifactorial. Proposed risk factors for PMVT following laparoscopic surgery include high intra-abdominal pressures, operation type, underlying disease process and length of surgery. Increased intra-abdominal pressure by carbon dioxide (CO2) insufflation causes a fall in mesenteric and portal venous flow due to the rise in intra-abdominal pressure.[2],[3] Some animal studies have shown that CO2 insufflation at lower intra-abdominal pressures of <12 mmHg results in moderate splanchnic hyperaemia [4] while other studies have suggested that transperitoneal diffusion of CO2 into the circulation can lead to systemic and mesenteric vasoconstriction.[2]

All the patients presented in this case report had more than one identifiable risk factor for venous thrombosis. Sogaard et al. identified the presence of more than one risk factor, for example, prothrombotic disorder or abdominal in at least 87% of their patients who presented with PVMT.[5]

Length of operating time significantly influences the risk of developing PMVT in patients. This risk is increased in laparoscopic surgery and is suggested to be secondary to increased stasis and the body's response to surgery.

To date, there is a lack of evidence in literature suggesting an optimal and cost-effective period of extended thromboprophylaxis in high-risk patients, following laparoscopic surgery. Indeed, this could be due to the low incidence of PMVT, which may not justify the blanket use for extended thromboprophylaxis in all the patients.

We suggest extended thromboprophylatic use in high-risk patients following prolonged laparoscopic surgery until definitive guidelines are developed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 ¤ References Top

1.
Salinas J, Barros D, Salgado N, Viscido G, Funke R, Perez G, et al. Portomesenteric vein thrombosis after laparoscopic sleeve gastrectomy. Surg Endosc 2014;28:1083-9.  Back to cited text no. 1
    
2.
Jakimowicz J, Stultiëns G, Smulders F. Laparoscopic insufflation of the abdomen reduces portal venous flow. Surg Endosc 1998;12:129-32.  Back to cited text no. 2
    
3.
Odeberg S, Ljungqvist O, Sollevi A. Pneumoperitoneum for laparoscopic cholecystectomy is not associated with compromised splanchnic circulation. Eur J Surg 1998;164:843-8.  Back to cited text no. 3
    
4.
Blobner M, Bogdanski R, Kochs E, Henke J, Findeis A, Jelen-Esselborn S. Effects of intraabdominally insufflated carbon dioxide and elevated intraabdominal pressure on splanchnic circulation: An experimental study in pigs. Anesthesiology 1998;89:475-82.  Back to cited text no. 4
    
5.
Sogaard KK, Astrup LB, Vilstrup H, Gronbaek H. Portal vein thrombosis; Risk factors, clinical presentation and treatment. BMC Gastroenterol 2007;7:34.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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